WELCOME TO OUR PRACTICE

Transcription

1 Chart# WELCOME TO OUR PRACTICE On behalf of entire team at A Great Smile Dental, let me welcome you to our practice. We are grateful that you have chosen us to meet your dental needs, and trust that you will find your experience in our office to be pleasant, professional, and extraordinary. You may discover that we are different from the average dental practice. When you visit our office, you will find a unique and relaxing environment. Our team is friendly and attentive. All of our treatment is designed to be comfortable, to be long-lasting, and to exceed all your expectations. We use the latest technology and techniques our profession has to offer. In order to better serve you, we are enclosing in the Welcome Packet several important documents that will assist us to making your transition to our office as smooth as possible. Please read each one carefully so that you can become familiar with our practice philosophy and policies. We are happy to answer questions you may have at any time. Please find the enclosed Personal Information Sheet and Medical and Dental History questionnaire that should be filled our prior to your first appointment with us. Be sure to visit our website at. We look forward to serving all your dental needs for you and your family. Yours truly for better dental health, Ben Yaghmai, D.D.S. and the AGSD Team 8420 West Lake Mead Blvd, Suite 100 (702)

2 PATIENT ACKNOWLEDGEMENT Initial Our practice is committed to providing the best treatment for our patients. We encourage you to notify us of any changes to your health status. Initial No minor children (under the age 18 years old) will be treated without a parent present during treatment. A notarized letter giving a relative permission to bring a minor is acceptable. Initial As a condition of treatment by this office, I understand financial arrangements must be made in advance. Initial We accept Cash, Visa, MasterCard, Discover and American Express. Initial I hereby authorize and request my insurance company to pay directly to A Great Smile Dental that amount due on my claim for services rendered to my dependents or me. Initial As a courtesy to you, we will verify your insurance coverage. It is your responsibility to notify us immediately if your insurance company or/coverage changes. Initial The deductible and co-payments are due at the time of the treatment and not all services recommended are covered benefit by your insurance company. Initial I understand that dental services provided are charged directly to me and that I am personally responsible for payment. If I carry insurance, I understand this office help to prepare my insurance claim to assist in making collections from insurance and will credit such collection to my account. However this office cannot render services on the assumption that charges will be paid by your insurance company. Initial Your insurance policy is the contract between you, your employer and the insurance company. We are not a party to that contract. If by any reason my insurance company does not cover for a service you are fully responsible for the charged amount. Initial We reserve the right to charge $50 per hour for appointments cancelled or broken without 24 business hours advance notice. Initial Returned checks are subject to $25 fee, due immediately, and check writing privilege will be revoked. Initial Any balance past due over 90 days is subject to be sent to collection agency, I will be responsible for any fees associated to this matter. I also understand that in order to collect my debt, my credit history may be check through the use of my social security number or any other information I have given you. Initial I grant my permission to you and your agents, to telephone me at home or at my work to discuss matters related to this form. Initial As a courtesy we bill secondary insurance, but expect all co-payments at the time of service. We will refund or credit your account when all insurance payments have been received. I have read the above conditions and agree to their content. Signature Date

3 GETTING TO KNOW YOU Patient Information Patient Name Social Security Number Birthdate Home Address City, State, Zip Home Phone Marital Status Address Single Divorced Sex Male Mobile Phone Female Best phone number to reach you Primary Insurance Company Group Member ID Secondary Insurance Company Group Member ID Responsible Party Primary Insurance Subscriber Name Social Security Number Birthdate Home Address City, State, Zip Home Phone Marital Status Address Single Married Married Divorced Separated Separated Relationship to Patient Home Mobile Phone Home Secondary Insurance Subscriber Name Social Security Number Birthdate Mobile Best phone number to reach party Home Address City, State, Zip Home Phone Mobile Marital Status Address Single Married Divorced Separated Relationship to Patient Mobile Phone Best phone number to reach party Home Mobile How did you find our office? Referred by a friend/relative Insurance ZocDoc Yelp Other (please explain): Living in the Neighborhood FaceBook Google Search Who should we thank for referring you to our practice? Patient's Dental History (please select any that apply to you) 1. Y N 2. Y N 3. Y N 4. Y N 5. Y N 6. Y N 7. Y N 8. Y N 9. Y N 10. Y N 11. Y N 12. Y N 13. Y N 14. Y N I clench or grind my teeth during the day or while sleeping. My gums bleed while brushing or flossing. I avoid brushing part of my mouth due to pain. My gums feel tender or swollen. I have problems eating. I have had orthodontics. I have had facial or jaw injury. I have clicking or popping of my jaw. I have facial muscle pain. I have jaw joint pain. I chew on ice or hard foods? I eat sour foods regularly? I let candies melt in your mouth? I enjoy different forms of sweets on a daily basis? (eg: soda, energy drinks, chocolate, etc?)

4 PATIENT S HEALTH HISTORY I consider my health to be (please check one): Excellent Good Fair Poor Do you have or have you ever had any of the following? Please check Y for yes or N for no. 1. Y N Heart Disease 2. Y N Heart Murmur/Mitral Valve Prolapse 3. Y N Congenital Heart Disease 4. Y N Rheumatic Fever 5. Y N Abnormal Blood Pressure 6. Y N Prosthetic Heart Valve 7. Y N Pacemaker 8. Y N History of Bacterial Endocarditis 9. Y N Tuberculosis or Lung Disease 10. Y N Stroke 11. Y N Anemia 12. Y N Prolonged Bleeding Disorder/Bruise Easily 13. Y N Asthma 14. Y N Hay Fever 15. Y N Sinus Trouble 16. Y N Epilepsy/Seizures 17. Y N Ulcers 18. Y N Implants/Artificial Joints: Hip-Knee Other 19. Y N I smoke or use chewing tobacco. If yes, how much per day? 20. Y N I have consumed alcohol within the last 24 hours. 21. Y N I usually take an antibiotic prior to dental treatment. 22. Y N Have you ever taken Fen-Phen or Redux? 23. Y N Liver Disease 24. Y N Jaundice 25. Y N Hepatitis Type 26. Y N Diabetes 27. Y N Excessive Urination and/or Thirst 28. Y N Infectious Mononucleosis ( Mono ) 29. Y N Herpes 30. Y N Arthritis 31. Y N Sexually Transmitted/Venereal Diseases 32. Y N Kidney Disease 33. Y N Tumor or Malignancy 34. Y N Cancer/Chemotherapy 35. Y N I have had major surgery. Year Type of operation Year Type of operation 36. Y N Radiation/Therapy 37. Y N History of Drug Addiction 38. Y N AIDS 39. Y N Immune Suppressed Disorder 40. Y N Hearing Loss 41. Y N Fainting Spells 42. Y N Glaucoma 43. Y N History of Emotional or Nervous Disorders 44. Y N Shunt in the body 45. Y N Breathing Problems 46. Y N Cold Sores/Fever Blisters 47. Y N Frequent Headaches WOMEN: 48. Y N Are you taking birth control medication? 49. Y N Are you or could you be pregnant or nursing? Are you allergic to any of the following? 50. Y N Aspirin 51. Y N Ibuprofin 52. Y N Sulfa Drugs/Sulfites/Sulfides 53. Y N Penicillin 54. Y N Codeine 55. Y N Latex, Metals, Plastics 56. Y N Local Anesthetics (Novocaine) 57. Y N Other Medications. If yes, which ones?

5 PATIENT S HEALTH HISTORY (cont.) 58. Y N Has anyone told you that you snore? 59. Y N Do you suffer from snoring? 60. Y N Do you wake up choking, gasping, or experiencing shortness of breath? 61. Y N Do you feel tired or fatigued during the day? 62. Y N Do you have any other medical problems or medical history NOT listed on this form? Please list all medications you are currently taking: Physician s Name Phone Address Fax I have accurately answered. I understand that providing incorrect information can be dangerous to my (or the patient s) health. It is my responsibility to inform the dental office of any changes in my (or the patient s) medical status. (Initial) In the event of an emergency please contact: Name Relationship Phone Name Relationship Phone Doctor s Notes: Medical/dental health reviewed by: X Doctor s Signature Date Patient s Signature (If patient is a minor: Parent/Guardian s signature)

6 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this Office Notice of Privacy Practices. I,, authorize A Great Smile Dental to release any and or all of my dental/medical information to the following recipients listed below: Signature Date FOR OFFICE USE ONLY We attempted to obtain written Acknowledgement of Receipt of Notice of Privacy Practice, but acknowledgement could not be obtained because: Individual refused to sign Communication barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify Below) Employee Signature Date